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Appendix VI MONITORING SYSTEM CERTIFICATION B, 06 2018 For Use By All Jurisdictions Within the State of California Authority Cited:Chapter 6.7,Health and Safety Code; Chapter 16,Division 3,Title 23,California Code of Regulations This form must be used to document testing and servicing of monitoring equipment.A separate certification or report�,UVJ�jp"X6F NTAL H EEALTH each monitoring system control panel by the technician who performs the work.A copy of this form must be provided to the tan IP owner/operator.The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days P es A. General Information Facility Name: TULARE FARMS Bldg.No.: Site Address: 2771 E. FRENCH CAMP RD city: FRENCH CAMP zip: 95336 Facility Contact Person: MIKE Contact Phone No.: ( Make/Model of Monitoring System, VEEDER ROOT TLS-350 Date of Testing/Servicing: 1/19/2018 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: Tank ID: 87 OCT Tank Size: 6 K Tank ID: DSL 2 Tank Size: 6 K El In-Tank Gauging Probe. Model: El In-Tank Gauging Probe. Model: 0 Annular Space or Vault Sensor. Model: 3 4 4 N Annular Space or Vault Sensor. Model: 3 4 4 El Piping Sump/Trench Sensor(s). Model: [I Piping Sump/Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Fill Sump Sensor(s). Model. ❑ Mechanical Line Leak Detector. Model: E] Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: E] Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Tank ID: Tank Size: Tank ID: Tank Size: [I In-Tank Gauging Probe. Model: El In-Tank Gauging Probe. Model: El Annular Space or Vault Sensor. Model: [I Annular Space or Vault Sensor. Model: El Piping Sump/Trench Sensor(s). Model: [I Piping Sump/Trench Sensor(s). Model: El Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: El Mechanical Line Leak Detector. Model: El Mechanical Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: El Other(specify equipment type and model in Section E on Page 2). El Other(specify equipment type and model in Section E on Page 2). Dispenser ID: GASOLINE Dispenser ID: DIESEL • Dispenser Containment Sensor(s). Model: VR- 00 1 0 Dispenser Containment Sensor(s). Model: VR- 00 I • ShearValve(s). ER ShearValve(s). ❑ Dispenser Containment Float(s)and Chain(s). ❑ Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: El Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: 0 ShearValve(s). El ShearValve(s). El Dispenser Containment Float(s)and Chain(s). 0 Dispenser Containment Float(s)and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: El Dispenser Containment Sensor(s). Model: El ShearValve(s). El Shear Valve(s). El Dispenser Containment Float(s)and Chain(s). El Dispenser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C.Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines.Attached to this Certification is information(e.g.manufacturers'checklists)necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment.For any equipment capable of generating such reports,I have also attached a copy of the report;(check all that apply): System set-up Alarm history report Technician Name(print): ZANE NIMMO Signature: Certification No.: A28446 License No: 04-1676 Testing Company Name: AFFORIDA-TEST Phone No. (209)744-0112 Testing Company Address: 416 2n,STREET GALT,CA 95632 Date of Testing/Servicing: 1/19/2018 Monitoring System Certification Page 1 of 4 2/21/07